Blood Cancer: Lymphoma

Because there are several different types of lymphoma, they’re often sorted into categories (groups), a process called classification. Classification is when the blood cells are examined and tested under a microscope to understand the type of lymphoma and how it might behave.

Tests can determine whether the lymphoma is a Hodgkins lymphoma or a non-Hodgkins lymphoma, which are the two main types of lymphoma.²

Hodgkins lymphoma
Dr Thomas Hodgkin was the first scientist to identify and describe lymphoma in 1832.

Hodgkins lymphoma can occur at any age, although most people diagnosed are between the ages of 15 and 35, or aged 60 and over. Over 1,800 people are diagnosed with Hodgkin lymphoma each year in the UK, and it seems to affect more men than women .³

Although Hodgkins lymphoma is a relatively aggressive cancer and can quickly spread through the body the success rates of Hodgkins lymphoma treatment through chemotherapy and radiotherapy is high and many patients are effectively treated.

Non-Hodgkins lymphoma
Non-Hodgkins lymphoma is any lymphoma that is not Hodgkins lymphoma. Each year in the UK, over 12,000 people are diagnosed with non-Hodgkins lymphoma, which is more common in people aged over 65.⁴

More specifically, non-Hodgkins lymphomas are classified by the type of lymphocyte they develop from, so they can be divided into either B-cell lymphomas (the majority of non-Hodgkins lymphomas) or T-cell lymphomas.

However, there are many different types of non-Hodgkins lymphoma, some of which grow slowly (called low-grade lymphomas) and others which grow at a faster rate when the cells appear to be dividing quite quickly (called high-grade lymphomas).

High-grade non-Hodgkins lymphoma
Non-Hodgkins lymphoma is called high grade, and some types of high-grade non-Hodgkins lymphoma can grow faster than others – these are sometimes called ‘aggressive’ lymphomas. But it’s important not to be too alarmed by this description – in fact, it’s the more aggressive lymphomas that are most likely to be cured.

High-grade non-Hodgkins lymphomas are more common in people aged over 50, but they can occur at any age.

Low-grade non-Hodgkins lymphoma
Non-Hodgkins lymphoma is called low grade when the cells appear to be dividing slowly – which mean that this condition can take a long time to develop. These types of non-Hodgkins lymphomas may sometimes be called ‘indolent’.

Knowing the type of lymphoma is important because it helps the medical team decide which treatment is best for you.

² Lymphoma Association, Different types of lymphoma. http://www.lymphomas.org.uk/about-lymphoma/types
³ Cancer Research UK http://www.cancerresearchuk.org/cancer-info/cancerstats/keyfacts/hodgkin-lymphoma/
⁴ NHS Choices, Non-Hodgkins Lymphoma. http://www.nhs.uk/Conditions/non-hodgkins-lymphoma/Pages/Definition.aspx

The exact cause of lymphomas isn’t understood, but a few factors can put people at risk, often because of a medical condition that in some way interferes with the immune system:

HIV infection or AIDS
Being infected with HIV (human immunodeficiency virus) or having AIDS (acquired immune deficiency syndrome) puts people at increased risk of developing some lymphomas.

Organ transplant
People who have had an organ transplant are more likely to develop lymphoma, because the drugs that prevent organ rejection interfere with the immune system – when his happens, it’s called a post-transplant lymphoproliferative disorder (PTLD).

Viral infections
Some lymphomas develops a result of certain viral infections, in particular the virus that causes glandular fever, called the Epstein–Barr virus (EBV).

Family history
In a few types of lymphoma having a direct relative (a parent or sibling) with lymphoma gives you a slightly higher risk of developing lymphoma too. But generally lymphoma isn’t inherited, and most people with the disease have no family history of lymphoma.

It has to be noted that these risk factors account for a small proportion of cases of lymphoma. In most cases, the cause of lymphoma isn’t yet known. And there is nothing to suggest that anything you do can cause you to develop lymphoma. You can’t catch lymphoma from someone and you can’t give it to anyone else.⁵

⁵ Lymphoma Associations, What causes lymphoma? http://www.lymphomas.org.uk/about-lymphoma/what-lymphoma/what-causes-lymphoma

The most common symptom of lymphoma is a painless swelling or lump, usually in the neck, armpit or groin area.

However, some lymphomas develop without any sign of a lump. Instead, the first symptoms of lymphoma may include:

• excessive sweating, especially at night
• fevers
• an unexplained loss of weight
• unusual tiredness
• persistent itching
• coughing or breathlessness
• abdominal pain or diarrhoea.

The symptoms you have will vary depending on where your lymphoma is growing. For example, if you have a lymphoma growing in your stomach, this might cause stomach ache, diarrhoea or constipation. If you have lymphoma in the bone marrow, you may get symptoms of anaemia.

Most people who notice these symptoms are unlikely to have lymphoma, as they are exactly like the symptoms of many more common and less serious illnesses too.

But you should always get any new or unusual symptoms looked into properly by a GP so you can treat any problems early.

Diagnosing lymphoma
If you go to your GP to talk about your symptoms, they will ask questions about your health and carry out a simple physical examination.

If your doctor thinks you need further tests, they will refer you to hospital, where a number of tests to could take place to confirm a diagnosis of Hodgkins lymphoma.

Biopsy
The main way to confirm a diagnosis is to take a biopsy, which involves removing some or all of an affected lymph node, which is then examined under a microscope in a laboratory.

Further tests
After a biopsy, more tests may be needed to see is the disease has spread – this also allows doctors to diagnose the stage of your lymphoma (this is called staging).

Blood tests
A blood test will help to determine your general health, the levels of red and white cells and platelets in your blood, and see how well your liver and kidneys are working.

Bone marrow sample
This is another type of biopsy to check if the cancer has spread to your bone marrow. It uses a long needle to remove a sample of bone marrow from your pelvis, and is performed using a local anaesthetic.

Chest X-ray
This may be used to see if the cancer has spread to your chest or lungs.

Computerised tomography (CT) scan
A CT scan takes a series of X-rays to build up a 3D picture of the inside of your body and check for any spread of cancer.

Magnetic resonance imaging (MRI) scan
An MRI scan uses strong magnetic fields to create a detailed image of the inside of your body to check for any spread of cancer.

Positron emission tomography (PET) scan
A PET scan is a test to measure the activity of cells in different parts of the body, and can visualise the spread of any cancer and see how treatment is working. A PET scan is usually taken the same time as a CT scan to examine how the tissues in different parts of the body are working.

Stages of lymphoma
When testing is complete, it should be possible to determine the stage of your lymphoma. Staging means describing the how far the cancer has spread, and the main stages of Hodgkins lymphoma are:

• Stage 1: Cancer is limited to one group of lymph nodes, such as your neck or groin nodes above or below your diaphragm
• Stage 2: Two or more lymph node groups are affected, either above or below the diaphragm
• Stage 3: Cancer has spread to lymph node groups above and below the diaphragm
• Stage 4: Cancer has spread through the lymphatic system into other organs and/or the bone marrow.

Health professionals can also use the letters ‘A’ or ‘B’ to your stage to show other symptoms.

‘A’ is shown after your stage if you have no additional symptoms other than swollen lymph nodes.

‘B’ is shown after your stage if you have additional symptoms of weight loss, fever and/or night sweats.

At BMI Healthcare, we use haemato-oncology to diagnose and treat all blood cancers, including lymphoma. Treatment in most cases is chemotherapy, sometimes in combination with radiotherapy.

Benefits of haemato-oncology
Treatment for most people with lymphoma helps to alleviate symptoms, improves survival and, for some people, can successfully treat the disease.

Once our doctors know the stage of your lymphoma, they can plan your treatment. The treatment type you will be offered depends upon a few factors, which includes your general health and the specific type (Hodgkins or non-Hodgkins) and stage of your lymphoma.

Hodgkins lymphoma
The aim of Hodgkins lymphoma  treatment is to cure the disease while minimising damage to your future health. It should also be said that many people with Hodgkins lymphoma can achieve long-term remission.

Early-stage Hodgkins lymphoma is often treated with a short course of chemotherapy and radiotherapy to the enlarged lymph nodes.

Advanced-stage Hodgkins lymphoma is treated with a longer course of chemotherapy, and some people also have radiotherapy.

High-grade non-Hodgkins lymphoma
Just like Hodgkins lymphoma, treatment aims to cure the disease, and many people with high-grade non-Hodgkins lymphoma can achieve long-term remission.

High-grade non-Hodgkins lymphoma is almost always treated with intravenous combination chemotherapy. Combination chemotherapy simply means that several different drugs are used, and that combination will depend upon your individual situation.

Early-stage low-grade non-Hodgkins lymphoma
Early-stage low-grade non-Hodgkins lymphoma is referred to as stage 1 or sometimes stage 2 lymphoma – this means is that the lymphoma is affecting only one or two groups of lymph nodes in a limited area of the body, and there’s no reason to suspect that other organs are involved.

When first diagnosed, fewer than 20% of people with low-grade lymphoma have stage 1 or 2 lymphoma disease, which is often treated and sometimes cured by giving radiotherapy to the enlarged lymph nodes.

Advanced-stage low-grade non-Hodgkins lymphoma
Most people who have low-grade non-Hodgkins lymphoma have advanced-stage disease by the time they first see their doctors.

This means that the lymphoma is affecting several groups of lymph nodes or different areas of the body. In terms of stage, this is classed as stage 3 or 4 lymphoma and sometimes stage 2 lymphomas.

Advanced-stage low-grade non-Hodgkins lymphoma is difficult to cure completely. This means that it can flare up, go away with treatment, then return again. Sometimes the lymphoma needs treatment and sometimes not – but the disease is not likely to go away altogether.

The aim of treatment for people with advanced-stage low-grade non-Hodgkins lymphoma is to control the symptoms of the disease to allow a good quality of life and level of comfort – and there are many options available to achieve this goal.

Possible treatments
Your lymphoma treatment will be chosen on the basis of your individual situation, including what type of low-grade non-Hodgkins lymphoma you have, and your overall health.

If you feel well and you have been diagnosed with low-grade non-Hodgkins lymphoma it’s quite usual not to have treatment – this is sometimes called active monitoring or, more simply, ‘watch and wait'.

However, the active treatments that may be used for lymphoma are:

Chemotherapy
You may have treatment with a single chemotherapy drug or a combination of different drugs. Steroids are usually given with chemotherapy to improve its effect.

Intensive chemotherapy with stem cell transplant
Also called high dose chemotherapy, this is an intensive chemotherapy drug treatment that can help to improve the chances of controlling your lymphoma in the long term. It uses high doses of chemotherapy followed by a stem cell transplant.

Stem cell transplant
Some people with low-grade non-Hodgkins lymphoma may be offered treatments such as stem cell transplant.

A stem cell transplant is where stem cells are injected into your vein through a drip to replace stem cells that the high dose chemotherapy has killed.

Stem cells are essential to our survival – they are embryonic blood cells in your bone marrow that develop into red blood cells, white blood cells and platelets.

Having a stem cell transplant enables you to tolerate higher doses of chemotherapy, to give the drugs more chance of curing the lymphoma.

Radiotherapy
Radiotherapy may sometimes be offered to people whose low-grade non-Hodgkins lymphoma is confined to one area. This therapy is sometimes used in combination with high dose (intensive) chemotherapy treatments.

Follow up treatment
You’ll have regular check-ups following your treatment. How often and for how long depends on the kind of treatment that you had. At follow-up appointments, your consultant will ask how you’re feeling and examine you. You might also need a blood test, CT scan, ultrasound, X-rays or a combination.

Paying for your haemato-oncology treatment
Haemato-oncology costs are covered by most medical insurance policies, but please check with your insurer first.

If you are paying for your own lymphoma treatment the cost of the operation will be explained and confirmed in writing when you book the operation.

Ask the hospital for a quote beforehand, and ensure that this includes the consultants’ fees and the hospital charge for your procedure.

Want to know more?
If you’d like to read more about blood cancer, treatment or living with blood cancer, please visit cancerresearchuk.org.uk